What are your options if your relative has been assessed by a Multi-Disciplinary Team (MDT Assessment) who recommended they were eligible for NHS Continuing Healthcare Funding, but the ICB has since rejected that recommendation, and refused or withdrawn their care-funding?
If you missed part 1 catch up quickly here:
Well, if you agree with the negative outcome, then there’s nothing further to do in terms of pursuing this means of free-funded NHS care. Your relative will pass over to their local authority to see whether they can provide funding for their social care needs. That will involve a means-tested assessment and, if your relative has assets or investments over £23,250, then they will have to pay for their own care from private means i.e self-fund.
If, however, you disagree with the Integrated Care Board’s (ICB) negative outcome decision, then you must appeal – and do so resolutely and effectively – as this is your next chance to try and secure CHC Funding for your relative after the MDT. Remember, you only have 6 months to lodge an appeal from the time you receive the negative outcome decision.
At this stage, the chances of achieving CHC Funding are diminishing with every negative decision. So, our advice is to prepare well! We strongly recommend that, if you want help, you seek early professional support to bolster your chances of success.
Take your time to gather all the relevant evidence and prepare your appeal submissions carefully. This is usually done in writing, although that is not mandatory. But preparing succinct and pertinent appeal submissions is an acquired skill – even though the NHS National Framework suggests that you don’t need help or advocacy support. Some people do achieve a successful outcome by their virtue of sheer grind and their determination to fight for their relative’s rights. Visit our Care To Be Different website and access free resources and get our book “How To Get The NHS To Pay For Care” described by customers as an invaluable and accessible guide.
However, the majority of families simply have no idea how to navigate the NHS appeal process. CHC is a complex area and the rule book and guidance contained in the NHS National Framework takes some careful reading and understanding. Whilst the rules are intended for everyone to use – for NHS assessors and the lay public alike (remember the core principle of being ‘person centric’) – make no mistake, this is not a level playing field. The odds are heavily slanted in favour of the NHS i.e., not to grant CHC Funding, however, passionately you feel about your relative’s high levels of healthcare needs.
Nor it is surprising to hear that most families have no idea as to the level of evidence and detailed analysis needed to satisfy the eligibility criteria for CHC Funding and meet the high bar to success set by the NHS. Others, may be more informed but do not have the necessary skills or ability to argue against the NHS and present their relative’s case succinctly and robustly. Instead, they get side-tracked down a closed alley and become fixated on minor irrelevancies, or else unwittingly get tripped up and undermine their own case.
Some family representatives can be quite bullish at the outset about their own ability to fight the NHS single-handedly and win, which is to be applauded; but, sadly, when the going gets tough, often come a cropper and get dragged down in NHS bureaucratic red-tape, delays and have the wool pulled over their eyes – if they haven’t already been fobbed off or given up in sheer frustration!
Getting to grips with the National Framework is not easy. The latest July 2022 edition contains 187 pages of detailed guidance – where the NHS appointed assessors are trained in its application – and most of the public are not! So, families are already at a disadvantage from the outset. Unless you have plenty of time on your hands – literally hours and hours – and are prepared to battle this alone against seasoned ICB professionals – we strongly suggest you seek early professional help.
Getting it wrong will only mean more misery and frustration, whilst potentially having to pay huge ongoing care fees and a lengthy wait for your next appeal!
Avoid these common mistakes:
If the ICB rejects the MDT’s recommendations to grant CHC Funding, that can often be a ‘red flag to a bull’, causing families to send an immediate letter of indignation in response to the ICB. However, a knee-jerk reaction can be prejudicial and even highly detrimental to your case. You have 6 months from receipt of the outcome decision and there’s much to do in this window. Here’s our two top tips:
# (1). Don’t rush in and lodge your appeal immediately as doing so could adversely affect your chances of success.
ICBs are now far more pro-active since COVID than in previous years and are pushing cases forward to appeal with some alarming pace. This dramatic change of tactic has caught out many families who are simply not ready for their appeal. They mistakenly think that lodging their appeal quickly is a positive step – mistakenly thinking, “that’ll show the ICB!” But in practical terms, it could prematurely trigger the ICB into rapid action and aggressively push for an early appeal date.
However, despite limited GDPR timescales, from experience, it can sometimes take months (not weeks) to get hold of GP, hospital and care home records. Time is then needed to review and consider the records, before distilling the salient information into robust written appeal submissions – whilst taking into account the 4 Key Characteristics. That task alone can take many days, if not weeks – depending on the volume of records to be considered. So, if you’ve lodged your appeal in haste and don’t have all the necessary records and evidence available to support your relative’s appeal – you could well have blown this second chance of getting CHC Funding. And don’t expect the ICB to be sympathetic and voluntarily grant you an extension of time, as they will inevitably do whatever they can to protect their funds.
# (2). Conversely, don’t leave it too late either to get your act together and prepare for your appeal.
Too often, families just don’t comprehend how the CHC system works and what evidence and intricate level of detail is needed to win their relative’s battle for CHC Funding. Panic sets in when the realisation of the task ahead becomes too consuming, daunting and overwhelming. Panic escalates, especially knowing that the stakes are enormously high (ie care fees!) if they fail to get CHC for their relative and they’ll have to self-fund – and in doing so, erode the family’s inheritance! Then they seek help but, sadly, too often, it’s just before the appeal hearing date when little can be done at the 11th hour. Don’t let this become your downfall. Our message is clear: plan ahead and get early help if you need it.
It is vital to prepare for an appeal promptly and, if necessary, seek early professional support whilst there is still sufficient time left to collate supporting evidence and then draft your appeal submissions. Leave it too late, and you could well be fighting the appeal on your own and be staring down the barrel of your next and last real chance of appeal i.e., to NHS England – many more months down the line; all while care fees are accruing daily for the self-funder.
For further reading around the subject, take a look at these blogs: